Spirituality and Mental Health Care: What’s Our Role? Douglas Ziedonis, MD, MPH Professor and Chairman UMass Department of Psychiatry also featuring input from: Amy Wachholtz, PhD Mathieu Bermingham, MD Fernando de Torrijos, MA Grand Rounds Presented October 6, 2009

Patient’s Spirituality  Sacred

Space

– private and personal nature of the subject matter  One

of several broad areas about which you will want to learn in initial clinical interview  Part of Cultural Competence & Assessment  Requires reflection of clinician’s own religious and spiritual perspectives

Clinician’s Role  Does

it make a difference whether we engage with a patient about their sense of spiritual wellbeing?  Can we help our patients meet their spiritual or religious needs?  Can a clinician (or chaplain) who is not selfaware of their own questions of meaning assess a patient’s spiritual or religious needs?

Your own spiritual needs  Better

understand your own spiritual beliefs  Perform a formal spiritual self-assessment by taking a spiritual history on yourself  Spiritual self-care is integral to serving your patients  Presence requires being attentive to (mindful of) our own spiritual needs/distress.  Self-care can take the form of – reconnecting with family and friends – time alone (for meditation, playing a sport, recreational reading, nature watching, etc.) – community service or religious practice » Prayer or meditation, etc

Spirituality Gene? Why

is spirituality such a powerful and universal force? Why do so many people believe in things they cannot see, smell, taste, hear, or touch?  Is

it hardwired into our genes?  Spirituality is one of our basic human inheritances - an instinct.

Spiritual Assessment Dimensions Belief

and Meaning Vocation and Obligations Experience and Emotions Courage and Growth Ritual and Practice Community Authority and Guidance (Fitchett - 7 dimensions)

Clinicians should be able to…  take

a spiritual history  elicit a patient's spiritual and religious beliefs and concerns & try to understand them  relate the patient's beliefs to decisions that need to be made regarding care  try to reach some preliminary conclusions about whether the patient's religious coping is positive or negative  refer to pastoral care or the patient's own clergy as seems appropriate.‖

Clinical Interview  How

important is spirituality or religion to you / in your daily life? (follow with reflective listening – not barrage of questions) – Tell me in what ways spirituality (or religion) is important to you

 Do

you have a religious preference?

– What is it?  Do

you go to church, synagogue, mosque, or temple? How often? – Are there spiritual practices that you follow regularly? » Tell me about them

 Do

you believe in God or a Higher Power?

– How do you experience God in your daily life?

Spiritual Assessment: Explore questions ofClinical meaning,Interview: value and relationship Do

you think your life has purpose or meaning? – What things are most important to you? – What gives your life purpose or meaning? – What are important values or goals?

Do

you pray to God? How often? How do you think of God?

Three Questions What

helps you get through the tough times? Who do you turn to when you need support? What meaning does this experience have for you?

Spiritual Assessment: Can

you usually forgive someone who has done something wrong to you? – Tell me about a time

Do

you think anyone loves you? Do you love yourself?

FICA Spiritual Assessment F: Faith or beliefs – ―Tell me something about your faith or beliefs.‖  I: Importance & influence – ―How does this influence your health/well-being?‖  C: Community 

– ―Are you part of a supportive community?‖ 

A: Address or application – ―How would you like me to address these issues in your health care?‖

(Puchalski, 1999)

HOPE  H:

Sources of hope .

– What are their sources of hope, strength, comfort, peace and connectedness? This helps to define their basic spiritual resources.  O:

Organized religion.

– Are they a member of a religious group ? How active are they ?  P:

Personal spirituality and practices.

– What specific aspects do they find most helpful in their own life ? Prayer ? Meditation ? Music ?  E:

Effects on medical care issues and end of life issues.

– This can help focus the discussion back onto clinical management

SPIRITual History  S=

Spiritual belief system  P= Personal spirituality  I= Integration with spiritual community  R= Ritualized practices and restrictions  I= Implications for medical care  T= Terminal events planning

Roles for the Clinician  Catalyst

– Encourages spiritual and religious questions – Encourages patient’s personal discovery and dialogue – Stimulates social connection – Not a spiritual advisor or necessarily knowledgeable about patient’s religion

Roles for the clinician  Treats

the ―whole person‖ not just the disease  Responds with compassion  Affirms patient’s unique worth and dignity  Stands by patient in face of suffering and death

Inappropriate Roles of Clinician  Spiritual

or religious teacher/leader

– Ethical and boundary issues  Proselytizing

– Power position, unequal balance – Boundaries – Missionary service as possible exception

Recognize Common Spiritual Dilemmas  Unfairness—Why

me?  Unworthiness—I don’t want to be a burden  Hopelessness—What’s the point?  Guilt and punishment—I’m being punished but I led a good life  Isolation and anger—No one understands me  Vulnerability—I am afraid  Confusion—Why is this happening to me?  Abandonment—God (or family) doesn’t care

Common signs of spiritual distress include:   

 

Sense of isolation or withdrawal Sense of hopelessness Anger at God ―Why is this happening to me?‖ Feeling abandoned by God

Provide Resources Quality of presence of chaplain, staff, volunteer and the relationship will enhance all resources and activities  Essential to incorporate the diverse religious and cultural resources of residents  Religious services (diverse); video tapes of services 

– Altars, shrines honoring diverse religions of residents (in alcoves, gardens, as well as quiet rooms, chapels) – Prayer books, scriptures, spiritual texts 

Alternative healers ( Medicine Man) – Traditional healing practices, including use of herbs – Sacred and healing objects – Anointing oil for rituals and other blessings

Resources 

Music: – Religious: chanting, e.g., Hebrew cantor, Buddhist priest, Negro spirituals, sing hymns with residents, harpist – CD player/tape player and CDs, tapes – Nature sounds – Resident preference for music; always important Art and Drama Therapy

 

 

Gardens: Herb, flower, and vegetable Guided imagery , hypnotherapy Massage therapy Poetry – opportunity to create alone or with others – opportunity to listen

Recovery is . . . not

cure, but rather a way of living a meaningful life within the limitations of addiction, mental illnesss, or both a process of restoring self-esteem a symbol of a personal commitment to growth, discovery, and transformation a process of readjusting our attitudes, feelings, perceptions, and beliefs about ourselves, others, and life in general

The 12 Steps 1 – The Problem – admitted one was powerless and that their life is unmanageable Step 2 – Came to believe that a power greater than us could restore us to sanity Step 3 – Made a decision to turn our will and lives over to the Higher Power Step 4 – Made a searching and fearless moral inventory (both the assets and liabilities) Step 5 – Admitted to God, ourselves and another human being the exact nature of our wrongs Step

The 12 Steps 6 – Ready to have HP remove Character Defects  Step 7 – Humbly asked HP to remove shortcomings  Step 8 – Made a list of all persons we had harmed and became willing to make amends  Step 9 – Made direct amends to such people whenever possible – unless more harmful  Step 10 – Continued to take a personal inventory and admit when we are wrong  Step 11 – Ongoing prayer and meditation  Step 12 - Having had a spiritual awakening as a result of these steps – carried on the message to others  Step

“The spiritual life is not a theory. We have to live it.” (Alcoholics Anonymous, p 83, 1976)

Common R/S Tools  Prayer

 Hope  Meditation  Reading

faith-based literature  Finding spiritual role models for coping  Seeking spiritual support/connection  Seeking instrumental support  Religious reappraisal  Church attendance

Positive vs. Negative R/S Coping Positive Forms  Seek spiritual connection  Seek spiritual support  Religious assistance to forgive others  Asking forgiveness  Benevolent religious reappraisal  Religion as distraction  Collaborative problem solving w/God

Negative Forms  Interpersonal religious discontent  Punishing God reappraisal  Demonic reappraisal  Spiritual discontent  Reappraisal of God’s power

Pargament, et al.,1998

Why Integrate Spirituality into Treatment?  Patients

view spirituality as a potent resource  Spirituality can be predictive of better mental and physical health outcomes AND  Spirituality can be predictive of poorer mental and physical health outcomes  Patients would like to include a spiritual dimension in treatment

Conversation Fears 1.

Fears about getting into the conversation

2.

Fears about the content of the conversation

3.

Fears about how to get out of the conversation

OASIS Patient-Centered Spirituality Inquiry 1. INTRODUCE ISSUE IN NEUTRAL INQUIRING MANNER Positive-Active Faith Response Neutral-Receptive Response 2. INQUIRE FURTHER, ADJUSTING INQUIRY TO PATIENT’S INITIAL RESPONSE

Spiritually Distressed Response Defensive/Rejecting Response Kristeller, et al., 2005

3. CONTINUE TO EXPLORE FURTHER AS INDICATED

4. INQUIRE ABOUT WAYS OF FINDING MEANING AND A SENSE OF PEACE 5. INQUIRE ABOUT RESOURCES.

6. OFFER ASSISTANCE TO ACCESS RESOURCES (AS APPROPRIATE AND AVAILABLE) 7. BRING INQUIRY TO A CLOSE

Four existential, related issues that all people question from young children to the aged  Death:

our own, the inevitable loss of those we

love  The meaning of life: why are we alive, what is our purpose?  Freedom: while limited by reality, and biology, we choose daily and long term  Aloneness: paradoxically we live in a social context but face life and death alone

Jerome Berryman, Godly Play

The Role of Mindfulness in Medicine, Health Care and Society Fernando de Torrijos, MA [email protected]

Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness

Yoga-Prayer-Meditation Yogas citta-vrtti-nirodhah Yoga is the inhibition of the modifications of the mind -Contemplative Traditions -Boddhicitta

What is mindfulness? ―Mindfulness means paying attention in a particular way: on purpose, in the present moment and not judgmentally‖

Practicing Mindfulness The engagement in these stress reduction techniques provides and/or increase:

clarity of mind, sense of purpose, greater self-esteem, and personal commitment, All important elements to make necessary changes in our lives

From Automatic-Pilot to Intentionality Dis-Attention Dis-Connection Dis-Regulation Dis-Order Dis-Ease

Lost Stand still. The trees ahead and bushes beside you are not lost. Wherever you are is called Here. And you must treat it as a powerful stranger, must ask permission to know it and be known. The forest breathes. Listen. It answers, I have made this place around you, if you leave it you may come back again, saying Here. No two trees are the same to Raven. No two branches are the same to Wren. If what a tree or a bush does is lost on you, you are surely lost. Stand still. The forest knows where you are. You must let it find you. -David Wagoner (from the words of a Native American elder)